Page 18 - 2019 Benefit Guide Non-CA

GROUP ACCIDENT INSURANCE COVERAGE

Insured by Cigna

Accident insurance coverage provides a cash benefit when medical services are obtained due to a covered
accident. An accidental injury can be costly, especially if you are financially unprepared. Your current medical
coverage will help pay for expenses associated with an injury, but won’t cover all of the out-of-pocket expenses
you may face. Don’t wait until you are rushed to the emergency room to realize you need more protection

Eligibility:
All active, full-time Employees regularly working a minimum of 20 hours per week, who are United States citizens
or permanent resident aliens, working and residing in the United States and their U.S. citizen Spouse and
Dependent Children who are residing in the United States.
COVERAGE

Initial Care and Emergency Care
Emergency Care Treatment Limited to 1 per accident, 1 accident per month. $200
Physician Office Visit Limited to 1 per accident. $100
Diagnostic Exam Limited 1 per accident, 1 accident per month. $50
(x-ray or lab)
Ground / Water Ambulance $400
(to nearest hospital)
$1,600
Air Ambulance
Limited 1 per accident, 1 accident per month.
Hospitalization
Hospital Admission Limited to 1 per accident, 1 accident per month. $1,000
Hospital Stay Limited to 365 days, 1 stay per accident, 1 accident per month. $200 per day
Intensive Care Unit Stay Limited to 365 days, 1 stay per accident, 1 accident per month. $400 per day
Fractures (Non-Surgical / Surgical) Limited to 1 per accident
Skull $4,000 / $8,000
Hip or Thigh $4,000 / $8,000
Vertebrae or Pelvis $4,000 / $8,000
Upper Arm $1,000 / $2,000
Shoulder or Collarbone $1,000 / $2,000
Leg $1,000 / $2,000
Ankle $800 / $1,600
Kneecap $800 / $1,600
Lower Arm $800 / $1,600
Foot $800 / $1,600
Hand or Wrist $800 / $1,600
Upper Jaw $600 / $1,200
Lower Jaw $600 / $1,200
Bones of Face or Nose $600 / $1,200
Vertebral Processes $600 / $1,200
$200 / $400
Rib
More than 1 rib fracture pays 2 times the Benefit Amount
Coccyx $200 / $400

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